Notice of Privacy Practices

JOINT NOTICE OF PRIVACY PRACTICES AND

NOTICE OF ORGANIZED HEALTH CARE ARRANGEMENT

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. IF YOU HAVE ANY QUESTIONS ABOUT THIS NOTICE PLEASE CONTACT OUR “PRIVACY OFFICER” AT 714-845-8605.

We are required by law to maintain the privacy of protected health information and to provide you with this Notice of our legal duties and privacy practices with respect to protected health information. “Protected health information” is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services or payment of health care services.

This Notice was published and became effective on June 1, 2019. We are required to abide by the terms of this Notice currently in effect. We may change the terms of this Notice at any time. The new Notice will be effective for all protected health information that we maintain at that time. You may obtain a copy of any revised Notice by accessing our website, calling our Privacy Contact and requesting that a revised copy be sent to you in the mail, or asking for one at the time of your next appointment.

Organized Health Care Arrangement: Pacific Dental Services, LLC (“PDS”) provides business support services to a number of entities engaged in the practice of dentistry (“Dental Entities”). All of the Dental Entities are included in the Smile Generation website maintained by PDS, and the dental office locations operated by the Dental Entities are listed at the following URL: http://www.smilegeneration.com/SiteMap.aspx, as updated from time to time. PDS, its subsidiaries and the Dental Entities are participants in an Organized Health Care Arrangement for purposes of federal privacy requirements and, accordingly, they may share information about you with each other for treatment, payment and operations purposes as described in this Notice. As used in this Notice, the words “we,” “our” and “us” collectively refer to PDS, its subsidiaries and the Dental Entities. This Notice applies to all Dental Entities that provide health care to you.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION WITHOUT YOUR AUTHORIZATION

To Contact You: We may use your protected health information to contact you to remind you about appointments, inform you about treatment options, or advise you about other health-related benefits and services.

Treatment: We may use and disclose your protected health information to provide, coordinate or manage your health care and any related services. This includes coordinating your health care with a third party, consulting with another health care provider, or referring you to another health care provider. For example, your dentist may need to know if you have other health problems that might complicate your treatment and therefore may request your medical record from another health care provider that has provided treatment to you.

Payment: We may use and disclose your protected health information to obtain or provide payment for your dental services. This may include sharing information with the person or entity responsible for paying, such as your health insurer. Your insurance company or health plan may need your information for activities such as determining eligibility or coverage for insurance benefits and reviewing services provided to you. For example, we may give your insurance company information about your dental surgery so your insurance will pay for the care.

Operations: We may use or disclose your protected health information for our health care operations, such as to support our business activities and to ensure that quality dental care is provided. Some of these activities involve quality assessments, peer or employee review, training health care professionals, licensing and accreditation activities, data aggregation, compliance- or audit-related activities, and business planning and development. For example, we may use your information to evaluate the performance of our dentists and staff in providing care to you. We may also disclose your protected health information to another provider, health plan, or health care clearinghouse that has or has had a relationship with you for certain of its health care operations.

Business Associates: We may disclose your protected health information to third parties that perform services, such as billing or legal services. We have written contracts with third parties requiring them to protect the privacy of your protected health information.

Treatment Alternatives and Health-Related Products and Services: We may use or disclose your protected health information to provide you with information about certain products or services including to describe our participation in a dentist network or health plan network, products or services we provide or include in a plan of benefits, and alternative treatments, therapies, dentists or settings of care.

Family and Friends: We may disclose your protected health information to individuals, such as family and friends, who are involved in your care or who help pay for your care. We may do this if you tell us we can do so, or if you know we are sharing your information with these people and you do not object. If you are unavailable or unable to tell us your preference, we may also disclose your information if, based on our professional judgment, we believe that disclosing the information is in your best interest and you would not object. For example, we may assume you agree to disclosure of your information to your spouse if your spouse comes with you into the exam room or allow your spouse to pick up prescriptions, dental supplies and X-rays.

If you are a minor, you also may have the right to block parental access to your health information in certain circumstances, if permitted by state law. You can contact your dental provider or our Privacy Officer at the number at the top of this Notice.

OTHER USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION WITHOUT AUTHORIZATION

We may use or disclose your protected health information without your authorization in certain other circumstances, such as when required by law or for public health and safety purposes. We will comply with the legal requirements and limitations applicable to these circumstances.

As Required by Law: We may use or disclose your protected health information when and as required by federal, state or local law.

Public Health Activities: We may disclose your protected health information to a public health authority for public health activities such as to prevent or control disease, injury or disability; to respond to or report suspected abuse or neglect, non-accidental physical injuries, reactions to medications, or problems with products; and to comply with medication or product recalls.

Health Oversight Activities:We may disclose your protected health information to health oversight agencies, such as government agencies that oversee the health care system, government programs, or compliance with civil rights laws, for oversight activities such as audits, investigations, inspections and licensing.

Lawsuits and Disputes: We may use or disclose your protected health information in response to a court or administrative order in an administrative or judicial proceeding, or in response to a subpoena, discovery request or other legal process.

Law Enforcement: We may use or disclose your protected health information for law enforcement purposes, so as to respond to legal processes, identify or locate a suspect, provide information about crime victims, report crimes occurring on our premises, and report suspected crimes in a medical emergency.

Coroners, Medical Examiners and Funeral Directors: We may disclose your protected health information to a coroner or medical examiner to identify a deceased person or determine the cause of death or for other lawful activities, or to a funeral director, as necessary to allow him/her to carry out his/her activities.

Organ and Tissue Donation: If you are an organ or tissue donor, we may disclose your protected health information to organizations that handle organ procurement or organ, eye or tissue donation or transplantation.

Research: We may use and disclose your protected health information in preparation for research or for research if and as approved by an institutional review board or privacy board.

Serious Threat to Health or Safety; Disaster Relief: We may disclose your protected health information to appropriate individuals or organization when and as necessary to prevent a serious threat to the health and safety of a person (including yourself) or of the public. We may also disclose your protected health information to identify, locate or notify your family members or persons responsible for you in a disaster.

Military and Veterans: We may disclose your protected health information as required by military command or another government authority if you are a member of the armed forces.

National Security; Intelligence Activities; Protective Service: We may disclose your protected health information to federal officials for intelligence, counterintelligence and other national security activities authorized by law, including activities related to the protection of the President, other authorized persons or foreign heads of state, or related to the conduct of special investigations.

Workers’ Compensation: We may disclose your protected health information for workers’ compensation or similar work-related injury programs, to the extent permitted or required by law.

Inmates: We may disclose your protected health information to a correctional institution (if you are an inmate) or a law enforcement official (if you are in that official’s custody) as necessary (i) for the institution to provide you with health care; (ii) to protect your or others’ health and safety; or (iii) for the safety and security of the correctional institution.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION WITH YOUR AUTHORIZATION

All uses and disclosures of your protected health information not covered by this Notice will be made only with your written authorization. For example, we will not sell your protected health information without your written authorization. Federal and state laws may provide additional protections or further limit how we may use or disclose your protected health information. We will comply with these laws and, when necessary, ask for your authorization to use or disclose your protected health information. Examples of protected health information that may be subject to special protections include psychotherapy notes, genetic information, mental health information, HIV/AIDS test results or information, reproductive health information, sexually transmitted or other communicable disease information, and alcohol or substance use disorder information.

You may revoke any authorization, at any time, by notifying, in writing, our Privacy Contact. If you revoke your authorization, we will no longer use or disclose your protected health information as allowed by the authorization, except to the extent we have already relied on the authorization.

YOUR RIGHTS WITH RESPECT TO PROTECTED HEALTH INFORMATION

You have the following rights with respect to your protected health information. You may exercise these rights by submitting a written request to our Privacy Contact. Please contact our Privacy Contact with any questions about these rights.

Right to Inspect and Copy. You may inspect and obtain a copy of your protected health information maintained in your dental chart, including clinical and billing records and any other records that we use to make decisions about you. We may charge you a fee to cover costs of copying, mailing and associated supplies.

We may refuse to allow you to inspect or copy certain records, such as information compiled for legal actions and proceedings. If we deny your request, you may have a right to have this decision reviewed.

Right to Request Restrictions. You may request that we not use or disclose any part of your protected health information for a particular treatment, payment or health care operations-related purpose. You may also request that any part of your protected health information not be disclosed to particular family members or friends who may be involved in your care.

We are not required to agree to a restriction that you may request, unless you request to restrict the disclosure of your protected health information to a health plan for payment or health care operations-related purposes and the protected health information relates only to a health care item or service for which you have paid in full and not through insurance. If we agree to the requested restriction, we may still use or disclose your protected health information as needed for emergency treatment.

Right to Request Confidential Communications. You may request that we communicate with you via alternative means or at an alternative location. For example, you may request that we contact you using your work phone number, rather than a home phone number. We will accommodate reasonable requests and will not require an explanation for the request, but we may require you to provide additional information to ensure we can contact you and arrange for billing and payment.

Right to Amend. You may request an amendment of your protected health information to correct an error or omission. In certain cases, we may deny your request for an amendment. If we deny your request for an amendment, you have the right to file a statement of disagreement with us. We may prepare a rebuttal to your statement and, if we do, we will provide you with a copy of any such rebuttal.

Right to an Accounting of Disclosures. You may request an accounting of certain disclosures of your protected health information made within a period up to six years prior to your request. This accounting does not include disclosures made to you or with your authorization; for treatment, payment or health care operations; to family members or friends involved in your care or for notification purposes; and certain other disclosures. The right to receive this information is subject to certain exceptions, restrictions and limitations.

Right to Breach Notification. If we or one of our service providers improperly uses or discloses your protected health information in a way that compromises the privacy or security of that information (a “breach”), we will notify you as required by law.

Right to Paper Copy of This Notice. You may receive a paper copy of this Notice upon request, even if you have agreed to accept this Notice electronically.

QUESTIONS OR COMPLAINTS

We take our obligations to protect your privacy seriously. If you have any questions about this Notice, please contact our Privacy Contact. If you believe your privacy rights have been violated, you may submit a complaint to us via our Privacy Contact at the number at the top of this form or the Secretary of the U.S. Department of Health and Human Services. You will not be penalized for filing a complaint.

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*Regular value of at least $290. In absence of gum (periodontal) disease. New patients only. Cannot be combined with any other offers. Coupon must be presented at appointment. Limit 1 per patient. Subject to insurance restrictions; cannot be applied to insurance co-payments. Not valid for appointments with pediatric dentist.

**$50 off when a patient donates $25 or more to the Special Olympics of Texas. Maximum discount of $50 off. Monetary donations can be made at Hill Country Dentists or online at https://sotx-reg.brtapp.com/HillCountryDentists; receipt required to show proof of donation. Donations accepted between 08/01/19 and 09/30/19. Cannot be combined with any other offers. Coupon must be presented at appointment. Subject to insurance restrictions; cannot be applied to insurance co-payments or deductible. Limit 1 per patient. Excludes cleaning, exam, Digital X-rays, root planing and scaling and/or periodontal maintenance, and orthodontics. Excludes general anesthesia. Not valid for appointments with pediatric dentist, orthodontist, periodontist, endodontist or oral surgeon. AZ, CO, ID, and NM Delta Dental members: valid toward cosmetic dentistry only. No cash redemption value. If full value is not redeemed, no credit value. Offer expires 9/30/19.